mdt conference case

CASE PRESENTATION

Thanks to DR. BABAR YASINMEDICAL OFFICERHISTOPATHOLOGY for the preparation of this presentation

CASE 1

LEFT BREAST CORE BIOPSY

INVASIVE DUCTAL CARCINOMA, GRADE IINO LYMPHO VASCULAR INVASION SEEN

RIGHT BREAST, CORE BIOSPY

INVASIVE MAMMARY CARCINOMA FOVOUR INVASIVE LOBULAR CARCINOMA, GRADE II

NO LYMPHOVASCULAR INVASION SEEN

Histologic Grade (Nottingham Histologic Score)

  Glandular (Acinar)/Tubular Differentiation Score 1 (>75% of tumor area forming glandular/tubular structures) Score 2 (10% to 75% of tumor area forming glandular/tubular structures) Score 3 (<10% of tumor area forming glandular/tubular structures)  Nuclear Pleomorphism Score 1 (nuclei small with little increase in size in comparison with normal breast

epithelial cells, regular outlines, uniform nuclear chromatin, little variation in size) Score 2 (cells larger than normal with open vesicular nuclei, visible nucleoli, and

moderate variability in both size and shape) Score 3 (vesicular nuclei, often with prominent nucleoli, exhibiting marked variation

in size and shape, occasionally with very large and bizarre forms)  Mitotic Rate Score 1 (≤3 mitoses per mm2) Score 2 (4-7 mitoses per mm2) Score 3 (≥8 mitoses per mm2)

Overall Grade Grade 1 (scores of 3, 4, or 5) Grade 2 (scores of 6 or 7) Grade 3 (scores of 8 or 9)

IMMUNOHISTOCHEMICAL FEATURES

It is recommended that hormone receptor and HER2 testing be done on all primary invasive breast carcinomas and on recurrent or metastatic tumors.

If hormone receptors and HER2 are both negative on a core biopsy, repeat testing on a subsequent specimen should be considered, particularly when the results are discordant with the histopathologic findings.

Other biomarker tests (eg, Ki-67 or multigene expression assays) are optional.

ER & PRProportion Score

Positive Cells, %

Intensity Intensity Score

0 0 None 0

1 <1 Weak 1

2 1 to 10 Intermediate 2

3 11 to 33 Strong 3

4 34 to 66  

5 ≥67

The Allred score combines the percentage of positive cells and the intensity of the reaction product in most of the carcinoma. The 2 scores are added together

for a final score with 8 possible values.

HER2Result Criteria

Negative (Score 0)

No staining observed

Negative (Score 1+)

Incomplete, faint/barely perceptible membrane staining in >10% of invasive tumor cells

Equivocal (Score 2+)

Incomplete and/or weak to moderate circumferential membrane staining in >10% of invasive tumor cellsor Complete, intense, circumferential membrane staining in ≤10% of invasive tumor cells

Positive (Score 3+)

Complete, intense, circumferential membrane staining in >10% of invasive tumor cells

Ki-67 Testing The percentage of Ki-67 positive tumor cells determined by

IHC is often used to stratify patients into good and poor prognostic groups.

( leading edge, hot spots, overall average).

LEFT BREAST, CORE BIOPSY,ER

PR

HER 2

Ki67

RIGHT BREAST, CORE BIOPSYER

PR

HER2

Ki67

Luminal A- ER-positive/ PR-positive- HER2-negative- Low Ki67

Luminal B- ER-positive/ PR-positive- HER2-positive (or HER2-negative with high Ki67)

Triple negative/basal-like- ER-negative- PR-negative- HER2-negative

HER2 type- ER-negative- PR-negative- HER2-positive

Synchronous Bilateral Breast Carcinoma

Synchronous bilateral breast cancer is uncommon (incidence ranges between 0.3% and 12%.) but its incidence is likely to rise.

This wide range is in part due to the many definitions. Some physicians consider a contralateral cancer diagnosed within 1 year as a synchronous bilateral breast cancer. Others narrow the definition of synchronous bilateral breast cancers to those cancers which are diagnosed within 3 months of each other.

In general, patients with SBBC tend to have a worse prognosis.

Tumor Size

Important prognostic factor.

The single greatest dimension of the largest invasive carcinoma is used to determine T classification.

The best size for AJCC T classification should use information from imaging, gross examination, and microscopic evaluation.

Visual determination of size is often unreliable (carcinomas

often blend into adjacent fibrous tissue). The size by palpation of a hard mass correlates better with invasion of tumor cells into stroma with a desmoplastic response.

MARGIN EVALUATION

The specimen should be oriented in order for the pathologist to identify specific margins.

Sutures, Clips (Communication between surgeon & pathologist)

A positive margin requires ink on carcinoma.

Lymph Node Sampling and Reporting

Types of lymph nodes. Gross findings & sampling. Size of metastases- Isolated tumor cell clusters (ITCs) - Micrometastases- Macrometastases

GROSS FINDINDS LEFT MASTECTOMY Tumor bed size 3.2 x 2.4 x 2.2 cm 3 cm from nearest postero-inferior margin 4.5 cm from deep resection margin Multiple lymph nodes in axillary fat

OPINION Mucinous Adenocarcinoma MILLER PAYNE grade 3 Skin & Resection margins free of tumor 6 / 22 LNs, Positive for metastatic carcinoma Size of the largest metastatic deposit 0.5 cm

GROSS FINDINGS,RIGHT BREAST LUMPECTOMY AND AXILLARY CONTENT

Tumor bed measures 3.3 x 2.4 x 2.0cm 0.1 cm from medial resection margin 3 cm from lateral resection margin 1.0 cm from superior resection margin 1.5 cm inferior resection margin 1.2 cm from deep resection margin 0.8 cm anterior resection margin

Multiple lymph nodes in axillary fat

OPINION

INVASIVE LOBULAR CARCINOMA, 3.3 CM ASSOCIATED LOBULAR CARCINOMA IN SITU TUMOR EXTENDS UPTO THE MEDIAL RESECTION

MARGIN MILLER PAYENE GRADE 3 PERI NEURAL INVASION SEEN

Miller-Payne System Grade 1 No change or some alteration to individual malignant cells, but no

reduction in overall cellularity

Grade 2 A minor loss of tumor cells, but overall cellularity still high; up to 30% loss

Grade 3 Between an estimated 30% and 90% reduction in tumor cells

Grade 4 A marked disappearance of tumor cells such that only small clusters or widely dispersed individual cells remain; 90% loss of tumor cells

Grade 5 No malignant cells identifiable in sections from the site of the tumor; only vascular fibroelastotic stroma remains, often containing macrophages; however, ductal carcinoma in situmay be present.

CAP Treatment Effect: Response to Presurgical (Neoadjuvant) Therapy   In the Breast No known presurgical therapy No definite response to presurgical therapy in the invasive carcinoma Probable or definite response to presurgical therapy in the invasive carcinoma No residual invasive carcinoma is present in the breast after presurgical

therapy   In the Lymph Nodes No known presurgical therapy No lymph nodes removed No definite response to presurgical therapy in metastatic carcinoma Probable or definite response to presurgical therapy in metastatic carcinoma No lymph node metastases. Fibrous scarring, possibly related to prior lymph

node metastases with pathologic complete response No lymph node metastases and no prominent fibrous scarring in the nodes

Completion surgery specimen 31-03-2016

Specimen with overlying skin and Nipple Areola comples A grey white area measuring 2.5x 2.0x 1.0 cm.

Opinion:- FIBROSIS, CHRONIC INFLAMMATION & GIANT CELL

RESPONSE- NO RESIDUAL TUMOR SEEN